BLD-2025-1151_SignedPermit.pdf ITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10811 ASHBOURNE CT APN: 375 22 094
PERMIT NO: BLD-2025-1151
OWNER'S NAME: GOPALAKRISHNAN VIJAY AND SUNDAR AISHWARYA M
OWNER'S PHONE:831-210-2764
CONTRACTOR: CLEAN ROOFING
CONTRACTOR PHONE: 408-564-5829
DATE ISSUED: May 15. 2025 ISSUED BY:Abby Ayende VALUATION: 16740
JOB DESCRIPTION: REROOF; TEAR OFF;1/2" CDX; REPLACE AND RE -INSTALL TILE; 34 SQ; CLASS A
LICENSED CONTRACTOR'S DECLARATION:
NO: 1034462 EXP DATE: 12/31/2025
7000) of Division 3 of the Business & Professions
CONTRACTOR: CLEAN
I hereby affirm that I
Code and that my license
ROOFING LICENSED CLASS: D411 S D NFG AND LICENSED
DECKING
am licensed under the provisions of Chapter 9 (commencing with Section
is in full force and effect.
penalty of perjury one of the following three declarations:
and will maintain a certificate of consent to self -insure for Worker's Compensation,
Code, for the performance of the work for which this permit is issued.
as provided for by Section 3700 of the
I hereby affirm under
❑ I have
Labor
Section 3700 of the Labor Code, for the
not employ any person in any manner so as to
this certificate of exemption, I become subject to
with such provisions or this permit shall be
I. I have
and will maintain Worker's Compensation Insurance, as provided for by
of the work for which this permit is issued.
that in the performance of the work for which this permit is issued, I shall
subject to the Worker's Compensation laws of California. If, after making
Worker's Compensation provisions of the Labor Code, I must forthwith comply
revoked.
performance
❑ I certify
become
the
deemed
HAZARDOUS MATERIALS DISCLOSURE
& Safety Code, Sections 25505, 25533, and 25534. I
materials requirements under Chapter 6.95 of the California Health
M I have read the hazardous
will maintain compliance
handle hazardous
Air Quality Management
Sections 25505, 25533,
with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or
air contaminants as defined by the Bay Area
Chapter 9.12 and the Health & Safety Code,
material. Additionally, should I use equipment or devices which emit hazardous
District I will maintain compliance with the Cupertino Municipal Code,
and 25534.
EPA LEAD -SAFE DISCLOSURE
No:
Certified Renovator will be responsible for this project.
Firm Certification
❑ An EPA Lead -Safe
Certified Firm Name:
✓ No EPA Lead -Safe
Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
of the work which this permit is issued
I hereby affirm under
(Section AV7, Civil Code).
penalty of perjury that there is a construction lending agency for the performance
No
Yes El
Lender's Name:
Lender's Address:
APPLICATION CERTIFICATION
with all city and county ordinances and state
the above mentioned property for inspection
judgements, costs, and expenses which may
understands and will comply with all non -point
2025
I certify that I have read
laws relating to building
purposes. (We) agree to
accrue against said City
source regulations per
Signature keiy
this application and state that the above information is correct. I agree to comply
construction, and hereby authorize representatives of this city to enter upon
save indemnify and keep harmless the City of Cupertino against liabilities,
in consequence of the granting of this permit. Additionally, the applicant
the Cupertino Municipal Code, Section 9.18.
Vaal- Date May 15,
EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 365 DAYS AFTER ITS ISSUANCE,
OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 365 DAYS AFTER THE TIME THE WORK IS COMMENCED.